Lincoln_Well Abandonment_20240423 (6)

!'EEL ABANDONMENT RECORD FoilmcmdU.wONLY;
This fohn cats be used I&single or nnillipte lolls
I.WCH C.Qntractor information: )HELL ABAN110N61ENT nETAi -; {
Brian Ewing 7a.Plumber of yrelis being(abandon.- 1
�S�etfCOl71[8C10f t\3nM of{t'CttOH'RLY 4OSL7t1 dsasutanla^{�Lil on9d5Pl�ef ra, For eiirlople. riveatot ur: mn-{rarer •surph• •wells' ONLY 'will .11w..same .
p t ?nl rnta:rroeor�i.i ainduieacwar,ivocimnihior'ota,jarm.
4240-B.
71r.Aliproxtmute voluine of stater;r6taining in well(s)2
NE'lVcpLbritfadorCCniticaliotiNtni>C,ct . ,
SAEDACCO FOR WATER SUPPLYiYELLSONLY.
�..
ContganyName 7cTypetifdisiofictanCused: � t
2:%Yell cuustntcdoh Permit tl:.
LLu�Ylaipltctiblc,uxNlarmitx(La_Ciwnh,Siet!,Yarlaare;L;srGara,.rrcltj@,uisn . 7d.Attiountof&Inf&tttnt'uK4 i
3.Well usi(eheckwell use): :I '
NVdter.Supply Well; ?c.Scaling rnatcrials tisctl(chcelz all that apply): :
pAgti`ulutral. p Manic-ip,A&Alic WNW Ccmcat Gtopt I d mraonitc Chips orpcllcts
E3Gcollicrmtl(Hs 014Cooling•Supply) pltcsidential WatcrSuopi}•(single) d Sand CeHwnt Grout 17 Dry C13Y
dbultistriallComnu n ia1 ❑liesidential'%Vater Supply:fshared) il C66deteGrout d I)dll;CltWngs
dhri�'tiros t7 Specialty Grout �; d Gravel
1Von-�Yatcr 5uppl�.'IVdt; ❑Bentoture Slurry. ❑Other(explain under 7g)
j9MotiitarLte, dRecavery
injection WCR: 7f.For each material selected above,pr6fide amoutit of.timterlals o'sed:
13Aquifer.l2ccliarge OGtotrntlutterRentediittipa Neat Cem.:941b ;Wtr:7ga1. ' Sand Cem.clb ,Wtr:gal.
ElAquifer,Stomge and Recover' 179 diitity Barrier
dAguiferTest 0Stonm uterMaim'ge
OEytetintemal Teehnolae_v 080sidence Colaral. i .
7g.Provide a brief dcceriptian df the al)"dnnment pntcLtid"f=
❑Geothennal(Closed Loop) dTracer
TREMI GROUT.FROM.THE BOTTOM.TO THE SURFACE
DGeothemiat(Heatinu)CdolinR Retum) Mother(explain under 71;) .
d.Date ncll(s).ahandoncd: 3-25-24 AA
5a.%Veil location:
Warlick's.Grocery
Fadlitla(hvtxrNmPc FadIity IDN(irappli able) 8:Celllltcaliau: „�'• ".'Jv
2673 Plateau Rd. Vale, NC 28168 Brian_.-Ewi11 4/2/2024
Physical'Addn ss,City;and Zip Si�Ralnri oCCcitlnc�f tiYeti C(�ntta tilt r.'ell(hetLr Due
Lincoln BY sisuing t1j&f&rr?:;I Item cerflfy•thN.Ills u•el!{s)was(ira 'done ire
Coimiy Parcelldaillltt6lmNo,(PIN) amvntanceWilt ISQ`.VC�IGQZC.QIQQ.iir2C.0?Q(?f(fell:Gan:sdnrcflan'Slnoektrxls
aril tlrid a cup}'ofiltis"recordhas h0-_01 proovided to the well owner.-
Sb,Nititude and iongitude In degrceslmiituteslsceonds'ordccimal degrees.
(irm:11 C.jti1,one 1;10t irg is S10001i) 9,.Site diagram or additional well details:
You nta}•use.tlie bak of this.page to piot,ide_additional nrli'site.*defails or isell
N abandoimteeu d'eottls.,You cua}alsn aitazb additioml paves if necessary_.
CE)NSTRif('ftt1N at TA1LS b(�YELLf51 BLtiNQ:'ABAND()NEb SUBMI711TAT.INSTRUM- ONS
:11lrxlr trcl!curt{•lruelieui t>•corilfs)if u{blhartk. fi�rinul6plr iitjretiatr'nu•fxtn�uxtiir.<uupply �. .
uxlds ONLY v nth flx smn�ciursrnenon'rt5roularinc u,iau[nn ndvrrii are tm. laa 'Fnr All.Welt%:' Submit-tbtis fond nithiu 30 dn}`s of•completion of urll
G:L Weil l� :MW-8A a4andoumcnt to the followu qg;
Disislonof Water Resoured,information Processing Unit,
61►•Totalacell depth. 95 (O,) 16171Hail,Seiviec Centeri,Raleinfi,NC 2769971617
lOb.'6r Tniectinn�Wdls: Lt addition to si tiding the fornt to the addi si.iti lt)a
Gc.Borehole dlamcter 2 nn,y abotr,also submit one sops of this forin within 30 days of completion of well
ubindomuent to tite fnllottidg: 1
1
fid Water tcvelbclan groand surface: (ft.) Di%istou of Wnter'Resouri4s�Undcrgr4und irijectlou Conitirl Prdgratn,
163E Mail$mice Center,Ralcigb,XC 27694-1636
6c Outer i asin g Ic n i 10c:Fnr 1V:itcr Surinh•A.Tnieetion Well's: In addition to-sending the form to
. �(of loon"n)• 00 the,address(es),above. also submit.one'copy° of this fount Wjlhin 30 days of
completion of well abandonment to the County IM1111 depannicin of tine county -
Gf.Tnnerenyin;/tubingdenjkb(if lmoyvn): (tlt.)
wherc ahadgncd,.
Gg.Screen Icni th(if!moan): A)
Feint GA'-30 -Nonh Carotim Dop mupew of Em ironmcaf and Ninumi RcsotLmcs-Dh•ision oMmerkesoameg Rcvisni Aagasi 2D l3
t